
| Recommendations | COR | LOE |
|---|---|---|
| Patients with severe VHD should be evaluated by a multidisciplinary Heart Valve Team when intervention is considered. | I | C |
Consultation with or referral to a Heart Valve Center of Excellence is reasonable when discussing treatment options for
| IIa | C |
| Stage | Definition | Description |
|---|---|---|
| A | At risk | Patients with risk factors for development of VHD |
| B | Progressive | Patients with progressive VHD (mild-to-moderate severity and asymptomatic) |
| C | Asymptomatic severe | Asymptomatic patients who meet the criteria for severe VHD: C1: Asymptomatic patients with severe VHD in whom the left or right ventricle remains compensated C2: Asymptomatic patients with severe VHD, with decompensation of the left or right ventricle |
| D | Symptomatic severe | Patients who have developed symptoms as a result of VHD |
| Low Risk (Must Meet ALL Criteria in This Column) | Intermediate Risk (Any 1 Criterion in This Column) | High Risk (Any 1 Criterion in This Column) | Prohibitive Risk (Any 1 Criterion in This Column) | |
|---|---|---|---|---|
| STS PROMa | <4% AND | 4%-8% OR | >8% OR | Predicted risk with surgery of death or major morbidity (all-cause) OR |
| Frailtyb | None AND | 1 index (mild) OR | ≥2 indices (moderate to severe) OR | >50% at 1 y OR |
| Major organ system compromise not to be improved postoperativelyc | None AND | 1 organ system OR | No more than 2 organ systems OR | ≥3 organ systems OR |
| Procedure-specific impedimentd | None | Possible procedure-specific impediment | Possible procedure-specific impediment | Severe procedure-specific impediment |
| a Use of the STS PROM to predict risk in a given institution with reasonable reliability is appropriate only if institutional outcomes are within 1 standard deviation of STS average observed/expected ratio for the procedure in question. b Seven frailty indices: Katz Activities of Daily Living (independence in feeding, bathing, dressing, transferring, toileting, and urinary continence) and independence in ambulation (no walking aid or assist required or 5-meter walk in <6 s). Other scoring systems can be applied to calculate no, mild-, or moderate-to-severe frailty. c Examples of major organ system compromise: Cardiac—severe LV systolic or diastolic dysfunction or RV dysfunction, fixed PHTN; CKD stage 3 or worse; pulmonary dysfunction with FEV1 <50% or DLCO2 <50% of predicted; CNS dysfunction (dementia, Alzheimer’s disease, Parkinson’s disease, stroke with persistent physical limitation); GI dysfunction—Crohn’s disease, ulcerative colitis, nutritional impairment, or serum albumin <3.0; cancer—active malignancy; and liver—any history of cirrhosis, variceal bleeding, or elevated INR in the absence of VKA therapy. d Examples: tracheostomy present, heavily calcified ascending aorta, chest malformation, arterial coronary graft adherent to posterior chest wall, or radiation damage. | ||||
| Recommendations | COR | LOE |
|---|---|---|
| TTE is recommended in the initial evaluation of patients with known or suspected VHD to confirm the diagnosis, establish etiology, determine severity, assess hemodynamic consequences, determine prognosis, and evaluate for timing of intervention. | I | B |
| TTE is recommended in patients with known VHD with any change in symptoms or physical examination findings. | I | C |
| Periodic monitoring with TTE is recommended in asymptomatic patients with known VHD at intervals depending on valve lesion, severity, ventricular size, and ventricular function. | I | C |
| Cardiac catheterization for hemodynamic assessment is recommended in symptomatic patients when noninvasive tests are inconclusive or when there is a discrepancy between the findings on noninvasive testing and physical examination regarding severity of the valve lesion. | I | C |
Exercise testing is reasonable in selected patients with asymptomatic severe VHD to
| IIa | B |
| Valve Lesion | ||||
|---|---|---|---|---|
| Stage | ASa | AR | MS | MR |
| Progressive (stage B) | Every 3-5 y (mild severity: Vmax 2.0-2.9 m/s) Every 1-2 y (moderate severity: Vmax 3.0-3.9 m/s) | Every 3-5 y (mild severity) Every 1-2 y (moderate severity) | Every 3-5 y (MVA >1.5 cm2) | Every 3-5 y (mild severity) Every 1-2 y (moderate severity) |
| Severe (stage C) | Every 6-12 mo (Vmax ≥4 m/s) | Every 6-12 mo Dilating LV: more frequently | Every 1-2 y (MVA 1.0-1.5 cm2) Once every year (MVA <1.0 cm2) | Every 6-12 mo Dilating LV: more frequently |
| Patients with mixed valve disease may require serial evaluations at intervals earlier than recommended for single valve lesions. a With normal stroke volume. | ||||
| Recommendations | COR | LOE |
|---|---|---|
| Secondary prevention of rheumatic fever is indicated in patients with rheumatic heart disease, specifically MS (Tables 7-8). | I | C |
| Agent | Dosage |
|---|---|
| Penicillin G benzathine | 1.2 million units IM every 4 wka |
| Penicillin V potassium | 250 mg orally BID |
| Sulfadiazine | 1 g orally QD |
| Macrolide or azalide antibiotic (for patients allergic to penicillin and sulfadiazine)b | Varies |
| a Administration every 3 wk is recommended in certain high-risk situations. b Macrolide antibiotics should not be used in persons taking other medications that inhibit cytochrome P450 3A, such as azole antifungal agents, HIV protease inhibitors, and some selective serotonin reuptake inhibitors. Adapted with permission from Gerber et al. Circulation. 2009;119:1541-1551. | |
| Type | Duration After Last Attack |
|---|---|
| Rheumatic fever with carditis and residual heart disease (persistent VHDa) | 10 y or until patient is 40 y of age (whichever is longer) |
| Rheumatic fever with carditis but no residual heart disease (no valvular diseasea) | 10 y or until patient is 21 y of age (whichever is longer) |
| Rheumatic fever without carditis | 5 y or until patient is 21 y of age (whichever is longer) |
| a Clinical or echocardiographic evidence. Adapted with permission from Gerber et al. Circulation. 2009;119:1541-1551. | |
| Stage | Definition | Valve Anatomy | Valve Hemodynamics | Hemodynamic Consequences | Symptoms |
|---|---|---|---|---|---|
| A | At risk of AS |
| Aortic Vmax <2 m/s | None | None |
| B | Progressive AS |
|
|
| None |
| C: Asymptomatic severe AS | |||||
| C1 | Asymptomatic severe AS | Severe leaflet calcification or congenital stenosis with severely reduced leaflet opening |
|
| None: Exercise testing is reasonable to confirm symptom status |
| C2 | Asymptomatic severe AS with LV dysfunction | Severe leaflet calcification or congenital stenosis with severely reduced leaflet opening |
| LVEF <50% | None |
| D: Symptomatic severe AS | |||||
| D1 | Symptomatic severe high- gradient AS | Severe leaflet calcification or congenital stenosis with severely reduced leaflet opening |
|
|
|
| D2 | Symptomatic severe low-flow/low-gradient AS with reduced LVEF | Severe leaflet calcification with severely reduced leaflet motion |
|
|
|
| D3 | Symptomatic severe low-gradient AS with normal LVEF or paradoxical low-flow severe AS | Severe leaflet calcification with severely reduced leaflet motion |
|
|
|
| Recommendations | COR | LOE |
|---|---|---|
| Diagnostic Testing | ||
| TTE is indicated in patients with signs or symptoms of AS or a bicuspid aortic valve for accurate diagnosis of the cause of AS, hemodynamic severity, LV size and systolic function, and for determining prognosis and timing of valve intervention. | I | B |
Low-dose dobutamine stress testing using echocardiographic or invasive hemodynamic measurements is reasonable in patients with stage D2 AS with all of the following:
| I | B |
| Exercise testing is reasonable to assess physiological changes with exercise and to confirm the absence of symptoms in asymptomatic patients with a calcified aortic valve and aortic velocity ≥4.0 m/s or ∆Pmean ≥40 mm Hg (stage C). | IIa | B |
| Exercise testing should NOT be performed in symptomatic patients with AS when the aortic velocity is ≥4.0 m/s or ∆Pmean is ≥40 mm Hg (stage D). | III: Harm | B |
| Medical Therapy | ||
| Hypertension in patients at risk for developing AS (stage A) and in patients with asymptomatic AS (stages B and C) should be treated according to standard GDMT, started at a low dose and gradually titrated upward as needed with frequent clinical monitoring. | I | B |
| Vasodilator therapy may be reasonable if used with invasive hemodynamic monitoring in the acute management of patients with severe decompensated AS (stage D) with NYHA class IV HF symptoms. | IIb | C |
| Statin therapy is NOT indicated for prevention of hemodynamic progression of AS in patients with mild-to-moderate calcific valve disease (stages B-D). | III: No Benefit | A |
| Recommendations | COR | LOE |
|---|---|---|
AVR is recommended in symptomatic patients with severe AS (stage D1) with:
| I | B |
| AVR is recommended for asymptomatic patients with severe AS (stage C2) and LVEF <50% with decreased systolic opening of a calcified aortic valve with an aortic velocity ≥4.0 m/s or ∆Pmean ≥40 mm Hg. | I | B |
| AVR is indicated for patients with very severe AS (stage C or D) when undergoing cardiac surgery for other indications when there is decreased systolic opening of a calcified aortic valve and aortic velocity ≥4.0 m/s or ∆Pmean ≥40 mm Hg. | I | B |
AVR is reasonable for asymptomatic patients with severe AS (stage C1) with:
| IIa | B |
AVR is reasonable in apparently asymptomatic patients with severe AS (stage C1) with:
| IIa | B |
AVR is reasonable in symptomatic patients with low-flow/low-gradient severe AS with reduced LVEF (stage D2) with a:
| IIa | B |
AVR is reasonable in symptomatic patients with low-flow/low-gradient severe AS (stage D3) with LVEF ≥50%, a calcified aortic valve with significantly reduced leaflet motion, and a valve area ≤1.0 cm2 only if clinical, hemodynamic, and anatomic data support valve obstruction as the most likely cause of symptoms and data recorded when the patient is normotensive (systolic BP <140 mm Hg) indicate:
| IIa | C |
| AVR is reasonable for patients with moderate AS (stage B) with an aortic velocity 3.0-3.9 m/s or ∆Pmean 20-39 mm Hg who are undergoing cardiac surgery for other indications. | IIa | C |
| AVR may be considered for asymptomatic patients with severe AS (stage C1) with aortic velocity ≥4.0 m/s or ∆Pmean ≥40 mm Hg if the patient is at low surgical risk and serial testing shows an increase in aortic velocity ≥0.3 m/s/y. | IIb | C |
| Recommendations | COR | LOE |
|---|---|---|
| Surgical AVR is recommended in patients who meet an indication for AVR with low or intermediate surgical risk. | I | A |
| For patients in whom TAVR or high-risk surgical AVR is being considered, a Heart Valve Team consisting of an integrated, multidisciplinary group of healthcare professionals with expertise in VHD, cardiac imaging, interventional cardiology, cardiac anesthesia, and cardiac surgery should collaborate to provide optimal patient care. | I | C |
| TAVR is recommended in patients who meet an indication for AVR who have a prohibitive risk for surgical AVR and a predicted post-TAVR survival >12 months. | I | B |
| TAVR is a reasonable alternative to surgical AVR in patients who meet an indication for AVR and who have high surgical risk for surgical AVR. | IIa | B |
| Percutaneous aortic balloon dilation may be considered as a bridge to surgical AVR or TAVR in patients with severe symptomatic AS. | IIb | C |
| TAVR is NOT recommended in patients in whom existing comorbidities would preclude the expected benefit from correction of AS. | III: No Benefit | B |
| Stage | Definition | Valve Anatomy | Valve Hemodynamics | Hemodynamic Consequences | Symptoms |
|---|---|---|---|---|---|
| A | At risk of AR |
| AR severity: none or trace | None | None |
| B | Progressive AR |
| Mild AR:
Moderate AR:
|
| None |
| C | Asymptomatic severe AR |
| Severe AR:
| C1:
C2:
| None; exercise testing is reasonable to confirm symptom status |
| D | Symptomatic severe AR |
| Severe AR:
|
|
|
| Recommendations | COR | LOE |
|---|---|---|
| TTE is indicated in patients with signs or symptoms of AR (stages A-D) for accurate diagnosis of the cause of regurgitation, regurgitant severity, and LV size and systolic function, and for determining clinical outcome and timing of valve intervention. | I | B |
| TTE is indicated in patients with dilated aortic sinuses or ascending aorta or with a bicuspid aortic valve (stages A and B) to evaluate the presence and severity of AR. | I | B |
| CMR is indicated in patients with moderate or severe AR (stages B-D) and suboptimal echocardiographic images for the assessment of LV systolic function, systolic and diastolic volumes, and measurement of AR severity. | I | B |
| Medical Therapy | ||
| Treatment of hypertension (systolic BP >140 mm Hg) is recommended in patients with chronic AR (stages B and C), preferably with dihydropyridine calcium channel blockers or ACE inhibitors/ARBs. | I | B |
| Medical therapy with ACE inhibitors/ARBs and beta blockers is reasonable in patients with severe AR who have symptoms and/or LV dysfunction (stages C2 and D) when surgery is not performed because of comorbidities. | IIa | B |
| Surgical Intervention | ||
| AVR is indicated for symptomatic patients with severe AR regardless of LV systolic function (stage D). | I | B |
| AVR is indicated for asymptomatic patients with chronic severe AR and LV systolic dysfunction (LVEF <50%) at rest (stage C2) if no other cause for systolic dysfunction is identified. | I | B |
| AVR is indicated for patients with severe AR (stage C or D) while undergoing cardiac surgery for other indications. | I | C |
| AVR is reasonable for asymptomatic patients with severe AR with normal LV systolic function (LVEF ≥50%) but with severe LV dilation (LVESD >50 mm or indexed LVESD >25 mm/m2) (stage C2). | IIa | B |
| AVR is reasonable in patients with moderate AR (stage B) while undergoing surgery on the ascending aorta, CABG, or MV surgery. | IIa | C |
| AVR may be considered for asymptomatic patients with severe AR and normal LV systolic function at rest (LVEF ≥50%, stage C1) but with progressive severe LV dilation (LVEDD >65 mm) if surgical risk is low. | IIb | C |
| Recommendations | COR | LOE |
|---|---|---|
| Diagnosis | ||
| An initial TTE is indicated in patients with a known bicuspid aortic valve to evaluate valve morphology, to measure the severity of AS and AR, and to assess the shape and diameter of the aortic sinuses and ascending aorta for prediction of clinical outcome and to determine timing of intervention. | I | B |
| Aortic magnetic resonance angiography or CT angiography is indicated in patients with a bicuspid aortic valve when morphology of the aortic sinuses, sinotubular junction, or ascending aorta cannot be assessed accurately or fully by echocardiography. | I | C |
| Serial evaluation of the size and morphology of the aortic sinuses and ascending aorta by echocardiography, CMR, or CT angiography is recommended in patients with a bicuspid aortic valve and an aortic diameter >4.0 cm, with the examination interval determined by the degree and rate of progression of aortic dilation and by family history. In patients with an aortic diameter >4.5 cm, this evaluation should be performed annually. | I | C |
| Surgical Intervention | ||
| Operative intervention to repair the aortic sinuses or replace the ascending aorta is indicated in patients with a bicuspid aortic valve if the diameter of the aortic sinuses or ascending aorta is >5.5 cm | I | B |
| Operative intervention to repair the aortic sinuses or replace the ascending aorta is reasonable in patients with bicuspid aortic valves if the diameter of the aortic sinuses or ascending aorta is >5.0 cm and a risk factor for dissection is present (family history of aortic dissection or if the rate of increase in diameter ≥0.5 cm per year). | IIa | C |
| Replacement of the ascending aorta is reasonable in patients with a bicuspid aortic valve who are undergoing aortic valve surgery because of severe AS or AR if the diameter of the ascending aorta is >4.5 cm. | IIa | C |
| Stage | Definition | Valve Anatomy | Valve Hemodynamicsa | Hemodynamic Consequences | Symptoms |
|---|---|---|---|---|---|
| A | At risk of MS |
| Normal transmitral flow velocity | None | None |
| B | Progressive MS |
|
|
| None |
| C | Asymptomatic severe MS |
|
|
| None |
| D | Symptomatic severe MS |
|
|
|
|
| a The transmitral ΔP mean should be obtained to further determine the hemodynamic effect of the MS and is usually >5-10 mm Hg in severe MS. However, due to the variability of the ΔPmean with heart rate and forward flow, it has not been included in the criteria for severity. | |||||
| Recommendations | COR | LOE |
|---|---|---|
| TTE is indicated in patients with signs or symptoms of MS to establish the diagnosis, quantify hemodynamic severity (ΔPmean, MVA, and PA pressure), assess concomitant valvular lesions, and demonstrate valve morphology (to determine suitability for mitral commissurotomy). | I | B |
| TEE should be performed in patients considered for PMBC to assess the presence or absence of left atrial thrombus and to further evaluate the severity of MR. | I | B |
| Exercise testing with Doppler or invasive hemodynamic assessment is recommended to evaluate the response of the mean mitral gradient and PA pressure in patients with MS when there is a discrepancy between resting Doppler echocardiographic findings and clinical symptoms or signs. | I | C |
Anticoagulation (VKA or heparin) is indicated in patients with
| I | B |
| Heart rate control can be beneficial in patients with MS and AF and fast ventricular response. | IIa | C |
| Heart rate control may be considered for patients with MS in normal sinus rhythm and symptoms associated with exercise. | IIb | B |
| Recommendations | COR | LOE |
|---|---|---|
| PMBC is recommended for symptomatic patients with severe MS (MVA ≤1.5 cm2, stage D) and favorable valve morphology in the absence of left atrial thrombus or moderate-to-severe MR. | I | A |
| MV surgery (repair, commissurotomy, or valve replacement) is indicated in severely symptomatic patients (NYHA class III-IV) with severe MS (MVA ≤1.5 cm2, stage D) who are not high risk for surgery and who are not candidates for or who have failed previous PMBC. | I | B |
| Concomitant MV surgery is indicated for patients with severe MS (MVA ≤1.5 cm2, stage C or D) undergoing cardiac surgery for other indications. | I | C |
| PMBC is reasonable for asymptomatic patients with very severe MS (MVA ≤1.0 cm2, stage C) and favorable valve morphology in the absence of left atrial thrombus or moderate-to-severe MR. | IIa | C |
| MV surgery is reasonable for severely symptomatic patients (NYHA class III-IV) with severe MS (MVA ≤1.5 cm2, stage D), provided there are other operative indications (eg, aortic valve disease, CAD, TR, aortic aneurysm). | IIa | C |
| PMBC may be considered for asymptomatic patients with severe MS (MVA ≤1.5 cm2, stage C) and valve morphology favorable for PMBC in the absence of left atrial thrombus or moderate-to-severe MR who have new onset of AF. | IIb | C |
| PMBC may be considered for symptomatic patients with MVA >1.5 cm2 if there is evidence of hemodynamically significant MS based on PAWP >25 mm Hg or mean MV gradient >15 mm Hg during exercise. | IIb | C |
| PMBC may be considered for severely symptomatic patients (NYHA class III-IV) with severe MS (MVA ≤1.5 cm2, stage D) who have suboptimal valve anatomy and who are not candidates for surgery or are at high risk for surgery. | IIb | C |
| Concomitant MV surgery may be considered for patients with moderate MS (MVA 1.6-2.0 cm2) undergoing cardiac surgery for other indications. | IIb | C |
| MV surgery and excision of the left atrial appendage may be considered for patients with severe MS (MVA ≤1.5 cm2, stages C and D) who have had recurrent embolic events while receiving adequate anticoagulation. | IIb | C |
| Stage | Definition | Valve Anatomy | Valve Hemodynamicsa | Hemodynamic Consequences | Symptoms |
|---|---|---|---|---|---|
| A | At risk of MR |
|
| None | None |
| B | Progressive MR |
|
|
| None |
| C | Asymptomatic severe MR |
|
|
| None |
| D | Symptomatic severe MR |
|
|
|
|
| a Several valve hemodynamic criteria are provided for assessment of MR severity, but not all criteria for each category will be present in each patient. Categorization of MR severity as mild, moderate, or severe depends on data quality and integration of these parameters in conjunction with other clinical evidence. | |||||
| Stage | Definition | Valve Anatomy | Valve Hemodynamicsa | Associated Cardiac Findings | Symptoms |
|---|---|---|---|---|---|
| A | At risk of MR |
|
|
| Symptoms due to coronary ischemia or HF may be present that respond to revascularization and appropriate medical therapy |
| B | Progressive MR |
|
|
| Symptoms due to coronary ischemia or HF may be present that respond to revascularization and appropriate medical therapy |
| C | Asymptomatic severe MR |
|
|
| Symptoms due to coronary ischemia or HF may be present that respond to revascularization and appropriate medical therapy |
| D | Symptomatic severe MR |
|
|
|
|
| a Several valve hemodynamic criteria are provided for assessment of MR severity, but not all criteria for each category will be present in each patient. Categorization of MR severity as mild, moderate, or severe depends on data quality and integration of these parameters in conjunction with other clinical evidence. b The measurement of the proximal isovelocity surface area by 2D TTE in patients with chronic secondary MR underestimates the true ERO due to the crescent shape of the proximal convergence. | |||||
| Recommendations | COR | LOE |
|---|---|---|
| Diagnosis | ||
| TTE is indicated for baseline evaluation of LV size and function, RV function and LA size, PA pressure, and mechanism and severity of primary MR (stages A-D) in any patient suspected of having chronic primary MR. | I | B |
| CMR is indicated in patients with chronic primary MR to assess LV and RV volumes, function, or MR severity and when these issues are not satisfactorily addressed by TTE. | I | B |
| Intraoperative TEE is indicated to establish the anatomic basis for chronic primary MR (stages C and D) and to guide repair. | I | B |
| TEE is indicated for evaluation of patients with chronic primary MR (stages B-D) in whom noninvasive imaging provides nondiagnostic information about severity of MR, mechanism of MR, and/or status of LV function. | I | C |
| Exercise hemodynamics with either Doppler echocardiography or cardiac catheterization is reasonable in symptomatic patients with chronic primary MR where there is a discrepancy between symptoms and severity of MR at rest (stages B and C). | IIa | B |
| Exercise treadmill testing can be useful in patients with chronic primary MR to establish symptom status and exercise tolerance (stages B and C). | IIa | C |
| Medical Therapy | ||
| Medical therapy for systolic dysfunction is reasonable in symptomatic patients with chronic primary MR (stage D) and LVEF <60% in whom surgery is not contemplated. | IIa | B |
| Vasodilator therapy is NOT indicated for normotensive asymptomatic patients with chronic primary MR (stages B and C1) and normal systolic LV function. | III: No Benefit | B |
| Recommendations | COR | LOE |
|---|---|---|
| MV surgery is recommended for symptomatic patients with chronic severe primary MR (stage D) and LVEF >30%. | I | B |
| MV surgery is recommended for asymptomatic patients with chronic severe primary MR and LV dysfunction (LVEF 30%-60% and/or LVESD ≥40 mm, stage C2). | I | B |
| MV repair is recommended in preference to MVR when surgical treatment is indicated for patients with chronic severe primary MR limited to the posterior leaflet. | I | B |
| MV repair is recommended in preference to MVR when surgical treatment is indicated for patients with chronic severe primary MR involving the anterior leaflet or both leaflets when a successful and durable repair can be accomplished. | I | B |
| Concomitant MV repair or MVR is indicated in patients with chronic severe primary MR undergoing cardiac surgery for other indications. | I | B |
| MV repair is reasonable in asymptomatic patients with chronic severe primary MR (stage C1) with preserved LV function (LVEF >60% and LVESD <40 mm) in whom the likelihood of a successful and durable repair without residual MR is >95% with an expected mortality rate of <1% when performed at a Heart Valve Center of Excellence. | IIa | B |
| MV repair is reasonable for asymptomatic patients with chronic severe nonrheumatic primary MR (stage C1) and preserved LV function (LVEF >60% and LVESD <40 mm) in whom there is a high likelihood of a successful and durable repair with 1) new onset of AF or 2) resting PHTN (PA systolic arterial pressure >50 mm Hg). | IIa | B |
| Concomitant MV repair is reasonable in patients with chronic moderate primary MR (stage B) undergoing cardiac surgery for other indications. | IIa | C |
| MV surgery may be considered in symptomatic patients with chronic severe primary MR and LVEF ≤30% (stage D). | IIb | C |
| MV repair may be considered in patients with rheumatic MV disease when surgical treatment is indicated if a durable and successful repair is likely or if the reliability of long-term anticoagulation management is questionable. | IIb | B |
| Transcatheter MV repair may be considered for severely symptomatic patients (NYHA class III-IV) with chronic severe primary MR (stage D) who have favorable anatomy for the repair procedure and a reasonable life expectancy but who have a prohibitive surgical risk because of severe comorbidities and remain severely symptomatic despite optimal GDMT for HF. | IIb | B |
| MVR should NOT be performed for treatment of isolated severe primary MR limited to less than one half of the posterior leaflet unless MV repair has been attempted and was unsuccessful. | III: Harm | B |
| Recommendations | COR | LOE |
|---|---|---|
| Diagnosis | ||
| TTE is useful to establish the etiology of chronic secondary MR (stages B-D) and the extent and location of wall motion abnormalities and to assess global LV function, severity of MR, and magnitude of PHTN. | I | C |
| Noninvasive imaging (stress nuclear/positron emission tomography, CMR, or stress echocardiography), cardiac CT angiography, or cardiac catheterization, including coronary arteriography, is useful to establish etiology of chronic secondary MR (stages B-D) and/or to assess myocardial viability, which in turn may influence management of functional MR. | I | C |
| Medical Therapy | ||
| Patients with chronic secondary MR (stages B-D) and HF with reduced LVEF should receive standard GDMT therapy for HF, including ACE inhibitors, ARBs, beta blockers, and/or aldosterone antagonists as indicated. | I | A |
| CRT with biventricular pacing is recommended for symptomatic patients with chronic severe secondary MR (stages B-D) who meet the indications for device therapy. | I | A |
| Surgical Intervention | ||
| MV surgery is reasonable for patients with chronic severe secondary MR (stages C and D) who are undergoing CABG or AVR. | IIa | C |
| MV repair or replacement may be considered for severely symptomatic patients (NYHA class III-IV) with chronic severe secondary MR (stage D) who have persistent symptoms despite optimal GDMT for HF. | IIb | B |
| MV repair may be considered for patients with chronic moderate secondary MR (stage B) who are undergoing other cardiac surgery. | IIb | C |
| Stage | Definition | Valve Anatomy | Valve Hemodynamicsa | Hemodynamic Consequences | Symptoms |
|---|---|---|---|---|---|
| A | At risk of TR | Primary:
| No or trace TR | None | None or in relation to other left heart or pulmonary/pulmonary vascular disease |
| B | Progressive TR | Primary:
| Mild TR:
| Mild TR:
| None or in relation to other left heart or pulmonary/pulmonary vascular disease |
| C | Asymptomatic severe TR | Primary:
|
|
| None, or in relation to other left heart or pulmonary/pulmonary vascular disease |
| D | Symptomatic severe TR | Primary:
|
|
| Fatigue, palpitations, dyspnea, abdominal bloating, anorexia, edema |
| a Several valve hemodynamic criteria are provided for assessment of severity of TR, but not all criteria for each category will necessarily be present in every patient. Categorization of severity of TR as mild, moderate, or severe also depends on image quality and integration of these parameters with clinical findings. | |||||
| Recommendations | COR | LOE |
|---|---|---|
| Diagnosis | ||
| TTE is indicated to evaluate severity of TR, determine etiology, measure size of right-sided chambers and IVC, assess RV systolic function, estimate PASP, and characterize any associated left-sided heart disease. | I | C |
| Invasive measurement of PA pressures and pulmonary vascular resistance can be useful in patients with TR when clinical and noninvasive data regarding their values are discordant. | IIa | C |
| CMR or real-time 3D echocardiography may be considered for assessment of RV systolic function and systolic and diastolic volume in patients with severe TR (stages C and D) and suboptimal 2D echocardiograms. | IIb | C |
| Exercise testing may be considered for the assessment of exercise capacity in patients with severe TR with no or minimal symptoms (stage C). | IIb | C |
| Medical Therapy | ||
| Diuretics can be useful for patients with severe TR and signs of right-sided HF (stage D). | IIa | C |
| Medical therapies to reduce elevated PA pressures and/or pulmonary vascular resistance might be considered in patients with severe functional TR (stages C and D). | IIb | C |
| Surgery | ||
| TV surgery is recommended for patients with severe TR (stages C and D) undergoing left-sided valve surgery. | I | C |
| TV repair can be beneficial for patients with mild, moderate, or greater functional TR (stage B) at the time of left-sided valve surgery with either 1) TA dilation or 2) prior evidence of right HF. | IIa | B |
| TV surgery can be beneficial for patients with symptoms due to severe primary TR that are unresponsive to medical therapy (stage D). | IIa | C |
| TV repair may be considered for patients with moderate functional TR (stage B) and PHTN at the time of left-sided valve surgery. | IIb | C |
| TV surgery may be considered for asymptomatic or minimally symptomatic patients with severe primary TR (stage C) and progressive degrees of moderate or greater RV dilation and/or systolic dysfunction. | IIb | C |
| Reoperation for isolated TV repair or replacement may be considered for persistent symptoms due to severe TR (stage D) in patients who have undergone previous left-sided valve surgery and who do not have severe PHTN or significant RV systolic dysfunction. | IIb | C |
| Stage | Definition | Valve Anatomy | Valve Hemodynamics | Hemodynamic Consequences | Symptoms |
|---|---|---|---|---|---|
| C, D | Severe TS | Thickened, distorted, calcified leaflets |
| RA/IVC enlargement | None or variable and dependent on severity of associated valve disease and degree of obstruction |
| The transtricuspid diastolic gradient is highly variable and is affected by heart rate, forward flow, and phases of the respiratory cycle. However, severe TS usually has ∆Pmeans >5-10 mm Hg at heart rate 70. | |||||
| Recommendations | COR | LOE |
|---|---|---|
| Diagnosis | ||
| TTE is indicated in patients with TS to assess the anatomy of the valve complex, evaluate severity of stenosis, and characterize any associated regurgitation and/or left-sided valve disease. | I | C |
| Invasive hemodynamic assessment of severity of TS may be considered in symptomatic patients when clinical and noninvasive data are discordant. | IIb | C |
| Intervention | ||
| TV surgery is recommended for patients with severe TS at the time of operation for left-sided valve disease. | I | C |
| TV surgery is recommended for patients with isolated, symptomatic severe TS. | I | C |
| Percutaneous balloon tricuspid commissurotomy might be considered in patients with isolated, symptomatic severe TS without accompanying TR. | IIb | C |
| Stage | Definition | Valve Anatomy | Valve Hemodynamics | Hemodynamic Consequences | Symptoms |
|---|---|---|---|---|---|
| C, D | Severe PR | Distorted or absent leaflets, annular dilation |
|
| None or variable and dependent on cause of PR and RV function |
| Stage | Definition | Valve Anatomy | Valve Hemodynamics | Hemodynamic Consequences | Symptoms |
|---|---|---|---|---|---|
| C, D | Severe PS |
| Vmax >4 m/s; peak instantaneous gradient >64 mm Hg |
| None or variable and dependent on severity of obstruction |
| Recommendations | COR | LOE |
|---|---|---|
| Diagnosis | ||
| An initial TTE study is recommended in patients after prosthetic valve implantation for evaluation of valve hemodynamics. | I | B |
| Repeat TTE is recommended in patients with prosthetic heart valves if there is a change in clinical symptoms or signs suggesting valve dysfunction. | I | C |
| TEE is recommended when clinical symptoms or signs suggest prosthetic valve dysfunction. | I | C |
| Annual TTE is reasonable in patients with a bioprosthetic valve after the first 10 years, even in the absence of a change in clinical status. | IIa | C |
| Antithrombotic Therapy | ||
| Anticoagulation with a VKA and INR monitoring is recommended in patients with a mechanical prosthetic valve. | I | A |
| Anticoagulation with a VKA to achieve an INR of 2.5 is recommended in patients with a mechanical AVR (bileaflet or current-generation single tilting disc) and no risk factors for thromboembolism. | I | B |
| Anticoagulation with a VKA is indicated to achieve an INR of 3.0 in patients with a mechanical AVR and additional risk factors for thromboembolic events (AF, previous thromboembolism, LV dysfunction, or hypercoagulable conditions) or an older-generation mechanical AVR (such as ball-in-cage). | I | B |
| Anticoagulation with a VKA is indicated to achieve an INR of 3.0 in patients with a mechanical MVR. | I | B |
| ASA 75-100 mg daily is recommended in addition to anticoagulation with a VKA in patients with a mechanical valve prosthesis. | I | A |
| ASA 75-100 mg daily is reasonable in all patients with a bioprosthetic aortic or MV. | IIa | B |
| Anticoagulation with a VKA is reasonable for the first 3 months after bioprosthetic MVR or repair to achieve an INR of 2.5. | IIa | C |
| Anticoagulation with a VKA to achieve an INR of 2.5 may be reasonable for the first 3 months after bioprosthetic AVR. | IIb | B |
| Clopidogrel 75 mg daily may be reasonable for the first 6 months after TAVR in addition to lifelong ASA 75-100 mg daily. | IIb | C |
| Anticoagulant therapy with oral direct thrombin inhibitors or anti-Xa agents should NOT be used in patients with mechanical valve prostheses. | III: Harm | B |
| Bridging Therapy | ||
| Continuation of VKA anticoagulation with a therapeutic INR is recommended in patients with mechanical heart valves undergoing minor procedures (such as dental extractions or cataract removal) where bleeding is easily controlled. | I | C |
| Temporary interruption of VKA anticoagulation, without bridging agents while the INR is subtherapeutic, is recommended in patients with a bileaflet mechanical AVR and no other risk factors for thrombosis who are undergoing invasive or surgical procedures. | I | C |
| Bridging anticoagulation with either IV UFH or SC LMWH is recommended during the time interval when the INR is subtherapeutic preoperatively in patients who are undergoing invasive or surgical procedures with a 1) mechanical AVR and any thromboembolic risk factor, 2) older-generation mechanical AVR, or 3) mechanical MVR. | I | C |
| Administration of fresh frozen plasma or prothrombin complex concentrate is reasonable in patients with mechanical valves receiving VKA therapy who require emergency noncardiac surgery or invasive procedures. | IIa | C |
| Administration of fresh frozen plasma or prothrombin complex concentrate is reasonable in patients with mechanical valves and uncontrollable bleeding who require reversal of anticoagulation. | IIa | B |
| Recommendations | COR | LOE |
|---|---|---|
| The choice of valve intervention, that is, repair or replacement, as well as type of prosthetic heart valve, should be a shared decision-making process that accounts for the patient’s values and preferences, with full disclosure of the indications for and risks of anticoagulant therapy and the potential need for and risk of reoperation. | I | C |
| A bioprosthesis is recommended in patients of any age for whom anticoagulant therapy is contraindicated, cannot be managed appropriately, or is not desired. | I | C |
| A mechanical prosthesis is reasonable for AVR or MVR in patients <60 y of age who do not have a contraindication to anticoagulation. | IIa | B |
| A bioprosthesis is reasonable in patients >70 y of age. | IIa | B |
| Either a bioprosthetic or mechanical valve is reasonable in patients between 60 and 70 y of age. | IIa | B |
| Replacement of the aortic valve by a pulmonary autograft (the Ross procedure), when performed by an experienced surgeon, may be considered in young patients when VKA anticoagulation is contraindicated or undesirable. | IIb | C |
| Recommendations | ||
|---|---|---|
| Prosthetic Valve Thrombosis | ||
| TTE is indicated in patients with suspected prosthetic valve thrombosis to assess hemodynamic severity and follow resolution of valve dysfunction. | I | B |
| TEE is indicated in patients with suspected prosthetic valve thrombosis to assess thrombus size and valve motion. | I | B |
| Fluoroscopy or CT is reasonable in patients with suspected valve thrombosis to assess valve motion. | IIa | C |
| Fibrinolytic therapy is reasonable for patients with a thrombosed left-sided prosthetic heart valve, recent onset (<14 days) of NYHA class I-II symptoms, and a small thrombus (<0.8 cm2). | IIa | B |
| Fibrinolytic therapy is reasonable for thrombosed right-sided prosthetic heart valves. | IIa | B |
| Emergency surgery is recommended for patients with a thrombosed left-sided prosthetic heart valve with NYHA class III-IV symptoms. | I | B |
| Emergency surgery is reasonable for patients with a thrombosed left-sided prosthetic heart valve with a mobile or large thrombus (>0.8 cm2). | IIa | C |
| Prosthetic Valve Stenosis | ||
| Repeat valve replacement is indicated for severe symptomatic prosthetic valve stenosis. | I | C |
| Prosthetic Valve Regurgitation | ||
| Surgery is recommended for operable patients with mechanical heart valves with intractable hemolysis or HF due to severe prosthetic or paraprosthetic regurgitation. | I | B |
| Surgery is reasonable for operable patients with severe symptomatic or asymptomatic bioprosthetic regurgitation. | IIa | C |
| Percutaneous repair of paravalvular regurgitation is reasonable in patients with prosthetic heart valves and intractable hemolysis or NYHA class III/IV HF who are at high risk for surgery and have anatomic features suitable for catheter-based therapy when performed in centers with expertise in the procedure. | IIa | B |
| Recommendations | COR | LOE |
|---|---|---|
| Prophylaxis | ||
Prophylaxis against IE is reasonable for the following patients at highest risk for adverse outcomes from IE before dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa:
| IIa | B |
| Prophylaxis against IE is NOT recommended in patients with VHD who are at risk of IE for nondental procedures (eg, TEE, esophagogastroduodenoscopy, colonoscopy, or cystoscopy) in the absence of active infection. | III: No Benefit | B |
| Recommendations | COR | LOE |
|---|---|---|
| Diagnosis | ||
| At least 2 sets of blood cultures should be obtained in patients at risk for IE (eg, those with congenital or acquired VHD, previous IE, prosthetic heart valves, certain congenital or heritable heart malformations, immunodeficiency states, or injection drug users) who have unexplained fever for more than 48 hours | I | B |
| or patients with newly diagnosed left-sided valve regurgitation. | I | C |
| The Modified Duke Criteria should be used in evaluating a patient with suspected IE (Tables 32-33). | I | B |
| Cardiac CT is reasonable to evaluate morphology/anatomy in the setting of suspected paravalvular infections when the anatomy cannot be clearly delineated by echocardiography. | IIa | B |
| TEE & TTE | ||
| TTE is recommended in patients with suspected IE to identify vegetations, characterize the hemodynamic severity of valvular lesions, assess ventricular function and pulmonary pressures, and detect complications. | I | B |
| TEE is recommended in all patients with known or suspected IE when TTE is nondiagnostic, when complications have developed or are clinically suspected, or when intracardiac device leads are present. | I | B |
| TTE and/or TEE are recommended for re-evaluation of patients with IE who have a change in clinical signs or symptoms (eg, new murmur, embolism, persistent fever, HF, abscess, or atrioventricular heart block) and in patients at high risk of complications (eg, extensive infected tissue/large vegetation on initial echocardiogram or staphylococcal, enterococcal, or fungal infections). | I | B |
| Intraoperative TEE is recommended for patients undergoing valve surgery for IE. | I | B |
| TEE is reasonable to diagnose possible IE in patients with S. aureus bacteremia without a known source. | IIa | B |
| TEE is reasonable to diagnose IE of a prosthetic valve in the presence of persistent fever without bacteremia or a new murmur. | IIa | B |
| TEE might be considered to detect concomitant staphylococcal IE in nosocomial S. aureus bacteremia with a known portal of entry from an extracardiac source. | IIb | B |
| Medical Therapy | ||
| Patients with IE should be evaluated and managed with consultation of a multispecialty Heart Valve Team including an infectious disease specialist, cardiologist, and cardiac surgeon. In surgically managed patients, this team should also include a cardiac anesthesiologist. | I | B |
| Appropriate antibiotic therapy should be initiated and continued after blood cultures are obtained, with guidance from antibiotic sensitivity data and infectious disease consultants. | I | B |
| It is reasonable to temporarily discontinue anticoagulation in patients with IE who develop CNS symptoms compatible with embolism or stroke, regardless of other indications for anticoagulation. | IIa | B |
| Temporary discontinuation of VKA anticoagulation might be considered in patients receiving VKA anticoagulation at the time of IE diagnosis. | IIb | B |
| Patients with known VHD should NOT receive antibiotics before blood cultures are obtained for unexplained fever. | III: Harm | C |
| Surgical Therapy | ||
| Decisions about timing of surgical intervention should be made by a multispecialty Heart Valve Team of cardiology, cardiothoracic surgery, and infectious disease specialists. | I | B |
| Early surgerya is indicated in patients with IE who present with valve dysfunction resulting in symptoms of HF. | I | B |
| Early surgerya is indicated in patients with left-sided IE caused by S. aureus, fungal, or other highly resistant organisms. | I | B |
| Early surgerya is indicated in patients with IE complicated by heart block, annular or aortic abscess, or destructive penetrating lesions. | I | B |
| Early surgerya for IE is indicated in patients with evidence of persistent infection as manifested by persistent bacteremia or fevers lasting longer than 5-7 days after onset of appropriate antimicrobial therapy. | I | B |
| Surgery is recommended for patients with PVE and relapsing infection (defined as recurrence of bacteremia after a complete course of appropriate antibiotics and subsequently negative blood cultures) without other identifiable source for portal of infection. | I | C |
| Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is indicated as part of the early management plan in patients with IE with documented infection of the device or leads. | I | B |
| Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is reasonable in patients with valvular IE caused by S. aureus or fungi, even without evidence of device or lead infection. | IIa | B |
| Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is reasonable in patients undergoing valve surgery for valvular IE. | IIa | C |
| Early surgerya is reasonable in patients with IE who present with recurrent emboli and persistent vegetations despite appropriate antibiotic therapy. | IIa | B |
| Early surgerya may be considered in patients with NVE who exhibit mobile vegetations >10 mm in length (with or without clinical evidence of embolic phenomena). | IIb | B |
a Early surgery is defined as during initial hospitalization before completion of a full therapeutic course of antibiotics. | ||
Definite IE | Pathologic criteria
|
Clinical criteria
| |
Possible IE |
|
Rejected
|
| Major Criteria | 1. Blood culture positive for IE Typical microorganisms consistent with IE from 2 separate blood cultures:
defined as follows:
|
2. Evidence of endocardial involvement
| |
| Minor Criteria | 1. Predisposition, predisposing heart condition, or injection drug use |
| 2. Fever, temperature >38° C (100.4° F) | |
| 3. Vascular phenomena, major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions | |
| 4. Immunologic phenomena: glomerulonephritis, Osler’s nodes, Roth’s spots, and rheumatoid factor | |
| 5. Microbiologic evidence: positive blood culture but does not meet a major criterion as noted abovea or serologic evidence of active infection with organism consistent with IE | |
| a Excludes single positive cultures for coagulase-negative staphylococci and organisms that do not cause IE. | |
| Recommendations | COR | LOE |
|---|---|---|
| Native Valve Stenosis | ||
| All patients with suspected valve stenosis should undergo a clinical evaluation and TTE before pregnancy. | I | C |
| All patients with severe valve stenosis (stages C and D) should undergo prepregnancy counseling by a cardiologist with expertise in managing patients with VHD during pregnancy. | I | C |
| All patients referred for a valve operation before pregnancy should receive prepregnancy counseling by a cardiologist with expertise in managing patients with VHD during pregnancy about the risks and benefits of all options for operative interventions, including mechanical prosthesis, bioprosthesis, and valve repair. | I | C |
| Pregnant patients with severe valve stenosis (stages C and D) should be monitored in a tertiary care center with a dedicated Heart Valve Team of cardiologists, surgeons, anesthesiologists, and obstetricians with expertise in the management of high-risk cardiac patients during pregnancy. | I | C |
| Exercise testing is reasonable in asymptomatic patients with severe AS (aortic velocity ≥4.0 m/s or ΔPmean ≥40 mm Hg, stage C) before pregnancy. | IIa | C |
| Medical Therapy | ||
| Anticoagulation should be given to pregnant patients with MS and AF unless contraindicated. | I | C |
| Use of beta blockers as required for rate control is reasonable for pregnant patients with MS in the absence of contraindication if tolerated. | IIa | C |
| Use of diuretics may be reasonable for pregnant patients with MS and HF symptoms (stage D). | IIb | C |
| ACE inhibitors and ARBs should NOTbe given to pregnant patients with valve stenosis. | III: Harm | B |
| Intervention | ||
| Valve intervention is recommended before pregnancy for symptomatic patients with severe AS (aortic velocity ≥4.0 m/s or ΔPmean ≥40 mm Hg, stage D). | I | C |
| Valve intervention is recommended before pregnancy for symptomatic patients with severe MS (MVA ≤1.5 cm2, stage D). | I | C |
| PMBC is recommended before pregnancy for asymptomatic patients with severe MS (MVA ≤1.5 cm2, stage C) who have valve morphology favorable for PMBC. | I | C |
| Valve intervention is reasonable before pregnancy for asymptomatic patients with severe AS (aortic velocity ≥4.0 m/s or ΔPmean ≥40 mm Hg, stage C). | IIa | C |
| PMBC is reasonable for pregnant patients with severe MS (MVA ≤1.5 cm2, stage D) with valve morphology favorable for PMBC who remain symptomatic with NYHA class III-IV HF symptoms despite medical therapy. | IIa | B |
| Valve intervention is reasonable for pregnant patients with severe MS (MVA ≤1.5 cm2, stage D) and valve morphology not favorable for PMBC only if there are refractory NYHA class IV HF symptoms. | IIa | C |
| Valve intervention is reasonable for pregnant patients with severe AS (ΔPmean ≥40 mm Hg, stage D) only if there is hemodynamic deterioration or NYHA class III-IV HF symptoms. | IIa | B |
| Valve operation should NOT be performed in pregnant patients with valve stenosis in the absence of severe HF symptoms. | III:Harm | C |
| Native Valve Regurgitation | ||
| All patients with suspected valve regurgitation should undergo a clinical evaluation and TTE before pregnancy. | I | C |
| All patients with severe valve regurgitation (stages C and D) should undergo prepregnancy counseling by a cardiologist with expertise in managing patients with VHD during pregnancy. | I | C |
| All patients referred for a valve operation before pregnancy should receive prepregnancy counseling by a cardiologist with expertise in managing patients with VHD during pregnancy regarding the risks and benefits of all options for operative interventions, including mechanical prosthesis, bioprosthesis, and valve repair. | I | C |
| Pregnant patients with severe regurgitation (stages C and D) should be monitored in a tertiary care center with a dedicated Heart Valve Team of cardiologists, surgeons, anesthesiologists, and obstetricians with expertise in managing high-risk cardiac patients. | I | C |
| Exercise testing is reasonable in asymptomatic patients with severe valve regurgitation (stage C) before pregnancy. | IIa | C |
| ACE inhibitors and ARBs should NOT be given to pregnant patients with valve regurgitation. | III: Harm | B |
| Intervention | ||
| Valve repair or replacement is recommended before pregnancy for symptomatic women with severe valve regurgitation (stage D). | I | C |
| Valve operation for pregnant patients with severe valve regurgitation is reasonable only if there are refractory NYHA class IV HF symptoms (stage D). | IIa | C |
| Valve repair before pregnancy may be considered in the asymptomatic patient with severe MR (stage C) and a valve suitable for repair, but only after detailed discussion with the patient about the risks and benefits of the operation and its outcome on future pregnancies. | IIb | C |
| Valve operations should NOT be performed in pregnant patients with valve regurgitation in the absence of severe intractable HF symptoms. | III:Harm | C |
| Prosthetic Valves | ||
| All patients with a prosthetic valve should undergo a clinical evaluation and baseline TTE before pregnancy. | I | C |
| All patients with a prosthetic valve should undergo prepregnancy counseling by a cardiologist with expertise in managing patients with VHD during pregnancy. | I | C |
| TTE should be performed in all pregnant patients with a prosthetic valve if not done before pregnancy. | I | C |
| Repeat TTE should be performed in all pregnant patients with a prosthetic valve who develop symptoms. | I | C |
| TEE should be performed in all pregnant patients with a mechanical prosthetic valve who have prosthetic valve obstruction or experience an embolic event. | I | C |
| Pregnant patients with a mechanical prosthesis should be monitored in a tertiary care center with a dedicated Heart Valve Team of cardiologists, surgeons, anesthesiologists, and obstetricians with expertise in the management of high-risk cardiac patients. | I | C |
| Medical Therapy | ||
| Therapeutic anticoagulation with frequent monitoring is recommended for all pregnant patients with a mechanical prosthesis. | I | B |
| Warfarin is recommended in pregnant patients with a mechanical prosthesis to achieve a therapeutic INR in the second and third trimesters. | I | B |
| Discontinuation of warfarin with initiation of IV UFH (with an aPTT >2 times control) is recommended before planned vaginal delivery in pregnant patients with a mechanical prosthesis. | I | C |
| Low-dose ASA (75-100 mg) once per day is recommended for pregnant patients in the second and third trimesters with either a mechanical prosthesis or bioprosthesis. | I | C |
| Continuation of warfarin during the first trimester is reasonable for pregnant patients with a mechanical prosthesis if the dose of warfarin to achieve a therapeutic INR is ≤5 mg daily after full discussion with the patient about risks and benefits. | IIa | B |
| Dose-adjusted LMWH at least 2 times per day (with a target anti-Xa level of 0.8-1.2 U/mL, 4-6 hours postdose) during the first trimester is reasonable for pregnant patients with a mechanical prosthesis if the dose of warfarin is >5 mg daily to achieve a therapeutic INR. | IIa | B |
| Dose-adjusted continuous IV UFH (with aPTT ≥2 times control) during the first trimester is reasonable for pregnant patients with a mechanical prosthesis if the dose of warfarin is >5 mg daily to achieve a therapeutic INR. | IIa | B |
| Dose-adjusted LMWH ≥2 times per day (with a target anti-Xa level of 0.8-1.2 U/mL, 4-6 hours postdose) during the first trimester may be reasonable for pregnant patients with a mechanical prosthesis if the dose of warfarin is ≤5 mg daily to achieve a therapeutic INR. | IIb | B |
| Dose-adjusted continuous infusion of UFH (with aPTT ≥2 times control) during the first trimester may be reasonable for pregnant patients with a mechanical prosthesis if the dose of warfarin is ≤5 mg daily to achieve a therapeutic INR. | IIb | B |
| LMWH should NOT be administered to pregnant patients with mechanical prostheses unless anti-Xa levels are monitored 4-6 hours after administration. | III:Harm | B |
| Recommendations | COR | LOE |
|---|---|---|
| Evaluation of Coronary Anatomy | ||
| Coronary angiography is indicated before valve intervention in patients with symptoms of angina, objective evidence of ischemia, decreased LV systolic function, history of CAD, or coronary risk factors (including men age >40 years and postmenopausal women). | I | C |
| Coronary angiography should be performed as part of the evaluation of patients with chronic severe secondary MR. | I | C |
| Surgery without coronary angiography is reasonable for patients having emergency valve surgery for acute valve regurgitation, disease of the aortic sinuses or ascending aorta, or IE. | IIa | C |
| CT coronary angiography is reasonable to exclude the presence of significant obstructive CAD in selected patients with a low/intermediate pretest probability of CAD. A positive coronary CT angiogram (the presence of any epicardial CAD) can be confirmed with invasive coronary angiography. | IIa | B |
| Intervention for CAD | ||
| CABG or PCI is reasonable in patients undergoing valve repair or replacement with significant CAD (≥70% reduction in luminal diameter in major coronary arteries or ≥50% reduction in luminal diameter in the left main coronary artery). | IIa | C |
| Intervention for AF | ||
| A concomitant maze procedure is reasonable at the time of MV repair or replacement for treatment of chronic, persistent AF. | IIa | C |
| A full biatrial maze procedure, when technically feasible, is reasonable at the time of MV surgery, compared with a lesser ablation procedure, in patients with chronic, persistent AF. | IIa | B |
| A concomitant maze procedure or pulmonary vein isolation may be considered at the time of MV repair or replacement in patients with paroxysmal AF that is symptomatic or associated with a history of embolism on anticoagulation. | IIb | C |
| A concomitant maze procedure or pulmonary vein isolation may be considered at the time of cardiac surgical procedures other than MV surgery in patients with paroxysmal or persistent AF that is symptomatic or associated with a history of emboli on anticoagulation. | IIb | C |
| Catheter ablation for AF should NOT be performed in patients with severe MR when mitral repair or replacement is anticipated, with preference for the combined maze procedure plus MV repair. | III: Harm | B |
| Recommendations | COR | LOE |
|---|---|---|
| Noncardiac Surgery in Patients With VHD | ||
| Moderate-risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring is reasonable to perform in patients with asymptomatic severe AS. | IIa | B |
| Moderate-risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring is reasonable to perform in patients with asymptomatic severe MR. | IIa | C |
| Moderate-risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring is reasonable to perform in patients with asymptomatic severe AR and a normal LVEF. | IIa | C |
| Moderate-risk elective noncardiac surgery in patients with appropriate intraoperative and postoperative hemodynamic monitoring may be reasonable to perform in asymptomatic patients with severe MS if valve morphology is not favorable for PMBC. | IIb | C |
| Size of Treatment Effect | |||||||||||||||
| Estimate of Certainty (precision) of Treatment Effect | CLASS I Benefit >>> Risk Procedure/Treatment SHOULD be performed/administered | CLASS IIa Benefit >> Risk Additional studies with focused objectives needed IT IS REASONABLE to perform procedure/administer treatment | CLASS IIb Benefit ≥ Risk Additional studies with broad objectives needed; additional registry data would be helpful Procedure/Treatment MAY BE CONSIDERED | CLASS III No Benefit or CLASS III Harm
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| LEVEL A Multiple populations evaluateda Data derived from multiple randomized clinical trials or meta-analyses |
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| LEVEL B Limited populations evaluateda Data derived from a single randomized trial or nonrandomized studies |
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| LEVEL C Very limited populations evaluateda Only consensus opinion of experts, case studies, or standards of care |
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| Suggested phrases for writing recommendations: | should is recommended is indicated is useful/effective/beneficial | is reasonable can be useful/effective/beneficial is probably recommended or indicated | may/might be considered may/might be reasonable usefulness/effectiveness is unknown/unclear/uncertain or not well established | COR III: No Benefit is not recommended is not indicated should not be performed/administered/other is not useful/beneficial/effective | COR III: Harm potentially harmful causes harm associated with excess morbidity/mortality should not be performed/ administered/other | ||||||||||
| Comparative effectiveness phrasesb: | treatment/strategy A is recommended/indicated in preference to treatment B treatment A should be chosen over treatment B | treatment/strategy A is probably recommended/indicated in preference to treatment B it is reasonable to choose treatment A over treatment B | |||||||||||||
| A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Even when randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective. | a Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior MI, history of HF, and prior aspirin use. b For comparative effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated. | ||||||||||||||
Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP III, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM III, Thomas JD. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
J Am Coll Cardiol 2014;63:e57–185. Copublished in Circulation 2014;129:e521-e643.
This Guideline attempts to define principles of practice that should produce high-quality patient care. It is applicable to specialists, primary care practitioners, and providers at all levels. This Guideline should not be considered exclusive of other methods of care reasonably directed at obtaining the same results. The ultimate judgment concerning the propriety of any course of conduct must be made by the clinician after consideration of each individual patient situation.
Neither IGC, the medical associations, nor the authors endorse any product or service associated with the distributor of this clinical reference tool.